Posted tagged ‘health care reform’

Competition often works. Competing dry cleaners or donut shops must either improve the quality of their product or keep their prices low, or customers will go somewhere else for their cruller fix. In time, the better businesses – the ones that provide tastier pastries at a lower price, – will thrive, and less-good, more-expensive businesses will go away. In the long run, all customers benefit from competition between businesses.

That’s how it’s supposed to be in the American marketplace. But the reality in health care is that it’s not a free market, and it can’t be a free market, and we cannot rely on competition to keep prices down. One big reason: health care prices are a secret.

You know how much a donut costs. If it’s too much, you’ll take your business elsewhere. Or eat a croissant, or (God forbid) a gluten-free muffin. But can you shop around to find better health care costs?

A quick story: I use a CPAP machine at night. (Apparently, if I don’t, I stop breathing. I’m told that’s bad.) I get billed $140 a month from the CPAP company, which is magically transformed into $42 a month on the insurance statement, which I pay towards my deductible. I called today to find out from the CPAP company what the total cost will be (it’s a rent-to-own deal, and eventually the machine will be paid off.) They wouldn’t tell me the total, but suggested I call my insurance company. Who also wouldn’t tell me the total, but assured me that if the CPAP company went over their “contractual rate”, the insurance company would stop paying. (How this helps me, I don’t know, but isn’t it nice to know that my insurance company won’t overpay? I might get hosed, but thankfully the good people at Aetna are protected from CPAP price gouging.) That “contractual rate”? It’s a secret (their computer knows, I was assured, but they can’t tell me.)

Even if I wanted to shop around for a less-expensive CPAP device, I couldn’t, because no one will tell me the price. Not that I would shop around, honestly – after those two phone calls, I’d rather poke a fork in my eye, or just stop breathing at night and let my wife shake me awake (which has always worked before. Maybe I need to start paying her that $42 a month.) Secret pricing and means that competition and comparison shopping just aren’t possible for many medical services.

There are other reasons that health care doesn’t abide by free-market principles:

Hospitals and emergency departments have to provide care to everyone, even if they can’t pay. Imagine running a grocery store where sometimes you had to give the food away. To stay in business, you’d have to jack up the prices on the paying customers to cover the non-payers. Now: emergency departments are not grocery stores, and I agree that it is morally unacceptable to turn sick people away. But someone has to pay for this. Emergency departments cannot be run like an ordinary competitive business.

The “barriers to entry” are too high to ensure competition. If a donut shop offers crappy, expensive donuts, another shop can open up across the street. But opening up a hospital is very expensive – and requires government clearance for a “certificate of need” and all sorts of other hoops. Pharmaceutical companies, device manufacturers – these are also very, very expensive companies to start up, and that stifles competition. Legal wrangling also gets in the way. There is no fair playing field to even out or control prices for the biggest-ticket medical expenses.

On the other hand, it’s relatively inexpensive to open up another walk-in or urgent care center – that’s why there’s one on every corner. At least in wealthy neighborhoods. You’d think that would create competition and lower prices – but that won’t happen, not unless their customers can comparison shop for price and quality. (By the way: judging the quality of medical care is also fraught.)

Many people don’t pay their own health care bills. We’ve come to expect health care to be covered by insurance (though that’s changing, with more high-deducible plans and cost-sharing). Many of us don’t even think to comparison shop. But if no one cares about the prices charged, “competition” doesn’t work.

Health care is often “purchased” under duress. When you’ve got crushing chest pain, you don’t call your insurance company to find an “in-network” hospital or ambulance service. And you shouldn’t have to.

The biggest problem with health care is that it costs too dang much. Providing better access to insurance and doctors is morally the right thing to do, but – and this is important, here – better access does not control costs. Competition, alone, won’t work. We’d better come up with some better ways to get costs under control, or there won’t be any money left over for those tasty donuts.

Care – /ker/ – The provision of what is necessary for the health, welfare, and protection of someone or something.

System – /’sistəm/ – A set of things working together as parts of a mechanism or an interconnecting network.

It’s not keeping us Healthy, it doesn’t seem to Care, and it’s certainly no kind of System. What we’re got is more about hostile parties protecting their turf and income than a system that’s working together. The docs fight the insurance companies to get things covered; the patients fight the hospitals over inflated, inscrutable bills; the insurance companies fight the pharmaceutical companies over the eye-popping prices of new drugs. The people least suited to fight end up losing the most – that’d be the “patients.”

Meanwhile: the peeps we’ve hired to fix this mess are too busy trying to make each other look bad – which, by the way, is like shootin’ fish in a barrel these days, amirite? – to pass some kind of legislation to even begin to help fix this fine mess. Ever get hired to do a job that you don’t do for 2 or 4 or 8 or 20 years? Didja keep that job? Mind: boggled.

OK, in the spirit of angering everyone involved, so I can bask in the flames of democrats and republicans alike, I will now specifically criticize the approach of both parties. Those of you with strong loyalties may want to skip the next (democratic) or following (republican) paragraphs, lest you be exposed to a worldview that’s not aligned with your own. But for the few of you left who are still capable of seeing two sides of an issue, start here:

Democrats: Obamacare has problems. The insurance marketplaces in many places are collapsing, and premiums are going thru the roof. Even people who have “insurance” often have huge deductibles that they can’t afford. In short: just having “insurance” isn’t the same as “having access to health care.” Obamacare didn’t do a thing to rein in the biggest problem: health care costs too much, and too many people (sorry, “market stakeholders”) are chewing up huge slices of the pie without contributing anything useful to helping patients. I know you’re feeling hurt that you lost the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

Republicans: The free market, alone, cannot save health care. The barriers to entry are too huge (it’s hard to become a doctor, harder to open up a company to manufacture medicines, and even harder to open up a hospital) – which means competition is artificially stunted, and won’t pop up automatically to reduce prices. Also, Emergency Departments are required, by law, to offer care to people who cannot pay – that’s morally the right thing, and don’t even think about removing this safety net. Health care choices are also difficult and fraught, and often made under the duress of pain and worry. People cannot be expected to call around to different ambulance companies to check their prices when they’re experiencing crushing chest pain. You have to admit: health care is unique, and you can’t depend on free market principles, alone, to fix it. The solution is going to include regulations and guidelines and (gasp) some guarantees of coverage, and might even require ways to rein in insco, hospital, doctor, and pharmaceutical profits. I know you’re feeling giddy that you won the last election, but can you please grow up, talk to the other side, and come up with some common ground to start to address the problems?

It’s not easy, I know – but at this point, it’s clear that members of both parties aren’t keeping their eyes on the ball. Your job isn’t about re-election, and payback, and “If you play with Susie than you can’t be my friend anymore.” This isn’t kindergarten, and we don’t really care who plays with Susie – we just want Susie and her family to have access to affordable, good health care. Congresspeople, it’s time to grow up and do your jobs.

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‘Tis a season, fraught and shrill. Volume has replaced thoughtful discourse. I realize many of us have long-ago made up our minds about the Affordable Care Act – and if you already know whether it’s good or it’s bad, this really isn’t the post for you. But if you’re one of the people in the eerie, quiet middle, curious for some context and facts, here’s one doc’s take on the status of what’s typically called “Obamacare.”

What are the problems?

There are two big ones, the way I see it. First, the whole program is not sustainable with the current model. When the ACA kicked in, the whole idea was to provide uninsured people with a way to purchase insurance plans, similar to the ones offered by employers. This looked like a big bumper crop of new customers for insurance companies, who initially lined up with all sorts of plans at affordable rates. The costs for consumers, at first, looked especially appealing, because government subsidies made premiums pretty cheap. At first.

But: insurance companies ended up taking a bath on those ACA insurance products. The people who signed up for them turned out to need more health care – to spend more money – than expected. The “young invincibles” who don’t need much health care spending aren’t signing up for these plans, despite having to pay a penalty. (The penalty is still cheaper than the premiums, and they can always sign up later if they develop a health problem. They’re young and invincible, but they’re not stupid.) Insurance companies have had to raise their rates, this year by an average of 10%, and in some areas as much as 55%. Many have exited this part of the insurance market entirely. It’s estimated that when enrollment starts in November, about 20% of people looking for individual plans in the ACA insurance exchanges will have only one plan from which to “choose.” And, of course, areas with fewer plans are seeing the highest rate increases.

Insurance companies would like to hold down rates, but so far their solutions have been both unsuccessful and unpalatable. Smaller “in-network” groups of physicians, hospitals, imaging centers, and labs do reduce costs. But inevitably that means clients – I mean, patients – have to wait longer for services, or travel farther, or navigate endless administrative roadblocks. Another idea to contain insco costs: increased deductibles and copays, which share more of the health care costs with patients.

Which brings us to the second Big Problem: many people are finding that their ACA-compliant plan is costing them, big time, to actually use. Just having health insurance doesn’t guarantee access to affordable health care if you’ve got huge deductibles and out-of-pocket expenses.

Have any parts of Obamacare worked?

Yes. The ACA has brought insurance to about 20 million Americans who lacked it, including about 9 million via expansion of state Medicaid programs to low-income families (that number could be much higher, if some states hadn’t refused to participate.) The uninsured rate has fallen from about 16% to 9%. Though deductibles can be high on some plans, people with insurance are at least protected against truly catastrophic costs from a serious hospitalization or chronic illness, like cancer or a heart attack.

Though premiums on the exchanges are rising, they’re actually about $600 a year below what was projected for 2016. And, overall, the rise in national health care costs has been reduced to record-lows, in part from ACA-required hospital cost-control and quality improvement mandates. Overall, federal government spending on health care in 2015 was $2.6 trillion less than it was expected to be – and that’s even with the 20 million more covered people in the system.

You’re full of sh*t. Obamacare is (the greatest thing ever)/(a complete disaster for everyone) <–ß you choose!

Yeah, well, see, I was hoping to weed out the partisans with that flowery introductory paragraph. People on either side of this issue seem to have a hard time seeing this from the other point of view. The very idea that “the other side” may have something worth saying and listening to doesn’t seem to jibe with the world of Facebook, Twitter, and the current election cycle. Democracy can be hard, but (I think) it’s the best system out there. Let’s give it a try!

OK, Hippie, we’ll try it your way. What do you suggest?

More young people need to sign up. This can be encouraged by increasing subsidies and/or increasing the penalty for non-insurance. Though forbidding insurance from excluding pre-existing conditions is a common-sense provision that needs to be retained, the rules can be tightened. People shouldn’t be allowed to take advantage of this by dropping insurance when they’re well and restarting it only when they get sick.

More flexibility will allow more competition, so people have a choice and premiums can be kept in check. Insurance companies should be allowed to offer products in any state, and regulations requiring certain kinds of coverage for all plans can be relaxed. People should be allowed to choose the kind of coverage they’re willing to pay for.

There are other good suggestions to improve the Affordable Care Act, but it will take a bipartisan congress of adults actually listening to each other to get it done. Their focus needs to be on making quality health care accessible, rather than protecting the profits of the insurance industry.

You’ve made some good points! Will you be our next Surgeon General?

I’ll consider it, but I certainly wouldn’t accept that nomination if <REDACTED> wins.

Parents, docs, and pundits are fuming. A life-saving, critical medication, used mostly in children, has become just about unaffordable for thousands of families. The Evil Drug Company Mylan has jacked up the price to over $500 over the last several years – this despite no increase in their costs. Congresspeeps, presidential candidates, and the ever-wise Facebook community all agree: Something must be done!

This isn’t the only example of weirdly-high prices for certain older drugs over the last few years. The system seems to be broken. To understand how best to fix it, it would be a good idea to go over just how the system was supposed to work.

After a drug is invented and tested, the company that developed it gets to sell it exclusively, under patent, for a set number of years. During that time the drug is only available as one “Brand Name”. The patent system is in place to reward the company for their innovation, allowing them to recoup their development costs, and make a profit. That encourages them to develop more new drugs, to make more money and to continue to bring new drugs into the marketplace. This part of the system certainly isn’t perfect – you can argue over just how many years drug companies should get exclusive rights to sell the drug they developed, and drug companies seem to be pouring more of their money into marketing and lobbying than into researching and developing new drugs. But the current problem really isn’t about new drugs or new patents.

What’s broken is the step that happens after the drug exclusivity patent expires. That’s when “generic” companies should be able to bring competing products to market. These are the same chemical, but packaged and sold by a different company. When multiple drug companies step in and produce generics, the market price of the drug falls precipitously. Many older drugs that now have multiple generic versions (including many antibiotics, statins, blood pressure, pain, and psychiatric meds) now have generics that are almost “free” – given away by grocery and pharmacy chains as loss-leaders. Yes, you can get a free supply of some antibiotics at Publix. That’s the marketplace at work. When it works, it works.

Except when it doesn’t. That price fall depends on generic companies being able to cheaply and easily bring the generic versions to market. Epinephrine, the medication in Epipen, has been around for decades, and it’s not under a patent. But regulatory issues have thwarted competitors from selling competing versions. One competitor, Auvi-Q, was recalled after a few dozen cases of wrong doses being dispensed by the device (to my knowledge no one was harmed by any of those errors.) In February, 2016 the FDA rejected Teva’s application for a generic epinephrine injector, and in June they delayed another company’s application, calling for expanded patient trials and more studies.

And it’s not just FDA regulations that gum up generic availability. Sometimes, drug manufacturers “pay off” generic makers to delay the introduction of generic medicines. These and other legal anti-competitive shenanigans create a marketplace that’s far from fair, preventing competition from driving down prices.

There is a very similar auto-injecting epinephrine device available, and it’s far cheaper: Adrenaclick. But the packaging and delivery system is different, so it’s not allowed to be freely generically substituted for an Epipen. If you want it, you have to have your prescriber specify that brand.

So: with no generic substitutions in sight, Mylan could freely increase their price. The same thing happens if there’s only one gas station in town, or only one health insurer in a local market. As we all learned from the board game, Monopolies are good for the monopoly, but bad for everyone else.

There’s more to the Epipen story. Mylan has been quietly jacking up the price for years, but no one really noticed until now. Until recently the list prices of medications were largely hidden from consumers. If you had health insurance, they paid the price, and you paid just a copay or whatever. Who cared what the “real” price was? Now that many of us have high deductible plans, those prices become important. Hiding the true cost of things from consumers, in the long run, doesn’t make for a fair or efficient marketplace.

And: you might imagine, with all of this price-gouging talk, you’d hear calls for someone’s head on a platter, in front of congress. Not this time. Mylan’s CEO is Heather Bresch, daughter of Senator Joe Manchin (D-West Virginia.)

The situation with the Epipen will wash out soon. The manufacturer has announced new cost-savings programs, and will almost certainly be lowering the list price shortly. But the regulatory framework that led to this disaster is still there, and until that’s addressed we’re going to be seeing more examples of crazy-priced drugs (and other medical services) soon.

“Customer service” is the new buzzword in health care. (Yes, I know it’s two words. Stay with me here.) Health care has become a service industry, like a restaurant or a company that comes to your home to replace a broken windshield. The shrimp is too salty, or the tech left footprints on your floor mat? You complain, and you send the shrimp back, and the tech apologizes and says “yes sir” and vacuums out your car. The customer, as we know, is always right.

Except in health care. Administrators and patients don’t want to hear this, but in health care the “customer” is not always right. And pretending that the customer is always right is costing us a whole lot of money and a whole lot of preventable sickness. We’re customer servicing ourselves into crappy health care, and docs and nurses seem to lack the power to prevent this from getting worse.

I’m part-owner of a few after-hours pediatric health clinics. Our sites are open when traditional pediatric practices are closed. Our patients – not customers– see genuine, board certified pediatricians for things like fever or sore throat or cough or ear pain. Common pediatric stuff. Rarely, we get complaints about or service or ugly remarks on Yelp, etc. Almost all of the negative reviews can be summarized like this: “I paid my money, and I didn’t get an antibiotic. I expect my antibiotic. I am the customer, and the customer is always right.” We don’t get comments about whether our doctors did a good and careful assessment, or whether they made a careful decision about recommendations. Nope, the customer is always right, and the customer wants an antibiotic. And if one isn’t given the customer is darn tootin going to complain about it.

We’ve had similar complaints on review sites about my own medical practice: “I brought in my child with a bad cold, and I didn’t even get an antibiotic! Zero stars for you!” I consider not giving antibiotics when they’re not needed – for a cold — a mark of a good practice. But someone skimming the reviews might just choose to go somewhere else. Perhaps a place that sees twice as many patients per hour, because explaining how to treat a cold correctly takes much longer than a quick antibiotic prescription.

It’s not just antibiotics, of course. In emergency departments all over the country, customer service and positive “reviews” are what drives physician salaries and hiring. You don’t make your patients happy, you’re going to take a pay cut or lose your job. But what if your patients – I’m sorry, customers – want something that isn’t good for them, like narcotics for chronic pain? We know narcotic addiction, driven by prescription products, is now the leading cause of accidental death in the US. But once patients become customers, they’re always right. And once doctors realize that negative reviews are going to cost them a job, what do you think is going to happen?

Of course, docs are being squeezed simultaneously in the other direction. The Feds don’t want us to “overprescribe” narcotics, either. They just want us to treat pain, quickly, and without our customers complaining. How exactly to do that is entirely up to us – we’re the doctors, of course, and no one would ever tell us what to prescribe – as long as we don’t use too much of the only drugs that work. Whatever “too much” is. That’s a secret. We’ll just monitor everything you do via your shiny new electronic medical record that you’re required to use. Which you hate. Please, don’t mind us.

One more example: I have here, mailed to my home, a flyer from my health insurance company. (I guess I shouldn’t tell you which one, but they’re huge, and you can rearrange the letters in their name to spell “Aetna.”) They offer a service, Teladoc, which costs “$40 or less”. Available “anytime, anywhere”, you get 24/7/365 access to “U.S. board-certified doctors” to treat things like “sinus problems, bronchitis, allergies” and “ear infection” over the phone! The doc can diagnose and prescribe medication for “many of your medical issues.” All without, you may have noticed, even pretending to do a physical exam. Or maybe they have a really long stethoscope that they can shove through the little tiny holes in their phones, or a 7 mile long swab to do a strep test. These clowns are going to know whether or not you need antibiotics without an exam, without touching you, without seeing you or without even being in the same room as you. That’s not medicine. It’s dark magic.

But you know what? They program will probably be successful. Because we know that many people don’t want a physician’s judgement – they just want antibiotics and prescriptions. So, with a wink and a nod, “Teledoc” gives us exactly what we’ve come to expect. The customer is always right. $40 out of pocket, and you can bet “Aetna”, or whoever they are, is saving some serious money by paying Teledoc next to nothing instead of paying a real doc to do a real evaluation. Everyone wins. Except you.

As philosopher Mick Jagger famously said, “You can’t always get what you want.” And at least in health care, you shouldn’t. Unfortunately, even if you try, it’s becoming harder to get what you genuinely need.

Researchers from Harvard, Stanford, and UCLA looked at data from admissions to Florida hospitals from 2000-2009, examining the rates of lawsuits filed against physicians versus the amount of money spent on the admission. Sure enough, in six of the seven specialties evaluated, there was a clear trend showing that at each step-up in spending, there was as step-down in the rate of lawsuits filed. For instance, in internal medicine the lowest fifth of spenders (~$20,000 for admission) had a 1.5% risk of a lawsuit; the highest fifth (~$40,000) had a risk of .3%. Double your spending, decrease your risk of a lawsuit by five times. Not a bad deal, really, for the doctors.

But was it a good deal for the patients? These investigators didn’t look at outcomes, but overall we know higher spending does not equal better care or healthier outcomes. More spending may seem to increase “patient satisfaction scores”, but high patient satisfaction negatively affects overall health. More tests often lead to the overdiagnosis of conditions that didn’t need to be treated, causing more worry and spending even more money.

So why do some docs spend more than others? This study reinforces the evidence for so-called defensive medicine: tests and procedures done only to ward off lawyers, the way garlic keeps away vampires. But garlic is cheap and harmless, and vampires are, well, imaginary. In the real world, docs are doing unnecessary tests and procedures, harming patients and flying through money, to stay out of the courtroom. Do I blame them? No. Is there a better way? I hope so.

I love seeing patients, and I love being a doctor—at least when I get a chance to be a doctor, in the short gaps left during the day when I’m done with telephone calls and “paperwork.” Here’s a few gems from my inbox this week.

From UnitedHealthcare came a letter reminding me that their “members” will incur additional costs if they use an out-of-network lab. This, I knew. We actually have a specific process in our office to steer patients toward their “in-network” labs, so they can save a few bucks. The new development came in this paragraph:

“If the member elects to receive services from a non-network lab, you must complete the Member Advance Notice Form, obtain the member’s signature on the form and retain it for your records.”

Wait—the member (I prefer to call them patients, but I’m old-fashioned) is the one who decided to go to a non-favored lab. So now it’s my job to obtain this form, get it signed, and keep it? I’m supposed to be UnitedHealthcare’s goon enforcer? Maybe I ought to get a truncheon and dimly lit room, you know, to convince them of the error of their ways. Those members, trying to make their own decisions. Fools!

Then this showed up: a subtle thing, but it rubbed me the wrong way.

A fax, addressed to my “Form Nurse.” I don’t have a “form nurse”! Nurses are there to care for the sick, to teach, to help deliver medical care. They’re part of my essential team. They are not just there to complete forms. If you’ve worked hard and gotten your nursing degree and license, and then someone wants you to be a “form nurse”—no patients, no icky touching people, just filling out forms, day after day—any nurse I know would just poke their own eyeballs out with a fork.

Of course, I’d rather them aim their forks at the UnitedHealthcare goons.

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